COMPLAINT FORM
PERSONAL INFORMATION
Complainant's Name
First Name
Last Name
Date of Birth
/
Month
/
Day
Year
Date
Age
Gender
CONTACT INFORMATION
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Telephone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Work Telephone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Other Means of Contacting Complainant
Cell Phone, Page, Email, etc.
INCIDENT INFORMATION
General Nature of Incident
Location of Incident
Day of the Week Incident Occurred
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Date of Incident
-
Month
-
Day
Year
Date
Time of Incident
Hour Minutes
AM
PM
AM/PM Option
Witnesses
Officers Involved
Name, Badge Number, Police District, if known.
Police Vehicle No. / Description
Physical Description of Officer(s)
Hair and Eye Color, Height, Sex, Race / Ethnicity, etc.
Describe injuries (if any)
Where treated (name of hospital, doctor, etc.)
Preferred Language of Communication (if other than English)
Name(s), Telephone Number(s) or Contact Information for Other People Present During the Incident
Describe the Incident
Describe the Incident (continued)
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